Monday, December 30, 2013

Dry humor, or wet seriousness, for the end of the old year


In February of 1958, classical music composer Milton Babbitt published his notorious article, “Who Cares If You Listen?”*  The article expressed indifference, or worse, to the listening audience who had hidebound tastes,** could not grasp the complexity of “serious” and “advanced” music, meaning serialism, and didn't like it.

There are psychotherapists with a similar sense of rectitude, which might be expressed: “We know what you need, what is good for you, and what your best is – whether you want it or not, and what your worst is – whether you want to ‘go there’ or not, and we will promote the ultimate good and cleave to the truth irrespective of your liking it or your improving.”

I know about these imperialists because I am sometimes one of them.  And I hope that very many of my fellow therapists are, too, because I’d hate to think we are pusillanimous dance partners whose definition of “help” is to masturbate our clients’ defenses.

Who masturbates their clients’ defenses?

* Therapists who practice the latest vogue, “strength-based counseling.”  This politically and bureaucratically correct inebriant, according to a University of Miami course outline, “represents a new paradigm in the field: from viewing clients primarily through a deficit lens, to a view that focuses on client strengths.”  “The aim of a strength-based counselor would be to identify and amplify client strengths, not on diagnosing problems.”***  See Appendix for an example of the strength-based approach.

* Therapists who assume that strengths are strengths, when they may be weaknesses.  Hope is a strength, unless someone continues to prostrate herself before a toxic parent, hoping for love that parent is incapable of.  “Hyperfocus” and hard work are strengths, unless you are hyper-avoiding the feeling world within and around you; unless you are struggling to be acceptable not worthless.  Kindness is a strength, unless it is the false self or your perfumey armor over shame.  Reasonableness is a strength, unless it is what grew over the corpse of your emotions, the fire of a feeling self.

* Therapists who believe in “solution-focused brief therapy,” another lobe job**** philosophy that believes pointing a rudderless ship to shore is good help.

Describing my paradigm at the beginning of a therapy – after the psychosocial assessment or a good listen to the client’s distress – I am saying that your problems fall within human nature as I understand it.  You have been hurt and have grown a wounded self.  The past is not the past, but the roots beneath your feet.  Time doesn’t heal – it masks and suffocates, abandons, intensifies, twists, corrodes.  Rarely if ever do clients demur from this benevolent approach.  What they do, sometimes, is request a psychiatric referral then substitute medications for therapy.  But in twenty years the only contrarian position I’ve heard has come from a student of counseling who was averse to the idea that one cannot smart-think one’s way out of mental pain.

And that long experience – that “my” people accept where I’m coming from – makes me wonder: Are there legions of strength-based, and solution-focused, and think-heavy (cognitive) therapists out there?  Clinicians who convince real people that capitalizing on their strengths will banish their ills?  Who convince real people that a new behavior or plan will change their different nature?  Who complexly out-reason their inferior-thinking clients?  Could it be just a reification of an echo – the way celebrities are famous for being famous – that the culture of psychotherapists buys these ideas, popular because we think they’re popular and therefore blessed?  Underground, are we actually authorities, brain surgeons in velvet gloves, Rachmaninoffs in Babbitts clothing?

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Appendix: Strength-Based Counseling

A man enters his strength-based Primary Care Physician’s office and says, “Doctor, I think I have cancer.  All the signs are present according to WebMD and my family history going back four generations.”  The doctor reassuringly says, “Don’t worry.  Let’s not focus on the negatives.  I hear you play a killer game of backgammon!”

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* http://www.palestrant.com/babbitt.html – Babbitt's ridiculous article that kills as it bores.
 
*** umbh.med.miami.edu/.  What terrible grammar!
 
**** “Lobe job.” The term comes from a science fiction story I read as a teenager.  A man in suspended animation wakes up in the far future.  Instead of finding an advanced civilization, he sees a decrepit cityscape, fallen to ruin from centuries of neglect, and nary a soul about.  He comes to learn (if I recall, in a disastrous way) that most of the population has succumbed to the pleasure of fantasy lobotomies "lobe jobs" by which they live out glorious lives of adventure, intrigue, etc. while lying comatose on a table.
 

Wednesday, December 25, 2013

Fantasy in f minor


I wanted to mention that while I sometimes reveal, in these posts, neurotic and dynamic features of my makeup, there is much that I will never say to anyone, that I will carry to the grave.  That content is not indiscretions or other colorful stuff, but what I know about the formative structure of my identity – the seed as it was and as it foretells the rest.  The fact that I can’t be alone in having “places” one does not want to dwell on – or dwell in – is a lesson about the shortcomings of the “primal” approach to psychotherapy that I cut my teeth on and still respect the most.  That is the approach that brilliantly questions the False Self and all defenses, sees Pain as the river that carves our landscape and undermines our subterranean self, and understands that repression is pathogenesis of mind and body.  I believe the best argument against primal purity is, “You can’t go home again.”  Pure openness – defenselessness – would be the untied balloon that deflating, lurches back to its formless, inchoate self.  Even exorcising his or her pain would not be enough.  Even counting on – a paradox the primal folk silently endorse – the “outer adult” to hold the cleansed-by-fire inner child would not be enough, if there was never a foundation to stand on.

Though physicists launch their minds into the universe while standing on a self-swallowing base of quantum uncertainty, free will determinism and ontological anarchy, I find my work slightly, and my writing significantly, braked by both the dark gooeyness of my foundation and the question of best psychology.  Sometimes I think of a person as an egg, whose shell is the defense system (drugs, denial, intellectualization, depression, workaholism, masturbation, violence, ad infinitum).  He is imprisoned within the shell – can’t really see out, can’t really live – but is not viable without it.  I wonder, sometimes, if best healing – by God and psychotherapists – would be to hold the hurting person in your arms while covering their eyes against their deepest truths.

A bigger problem for me is my own unsayable, which obliquely conforms to Yalom’s insight that in group therapy, so long as the members avoid discussing the elephant in the room – whatever the big issue is – nothing else of importance will happen.  While there are different subjects I may have a useful perspective on – such as anger management versus resolution, or client loneliness, or the narcissistic-sexualized front of my 21-year-old client – I often find these issues eclipsed by the dark sun of my own existence mystery.  And as my typing is invariably gravitationally drawn to the darkest forces, I’m pulled away from these livelier planets.



Tuesday, December 17, 2013

Tics


I’ve just returned from a very brief vacation with in-laws and young nephews, where the subject of tics did not come up.  As I am “the therapist” in an extended family with problems, I was struck by a distressing historical parallel which I helped create, but may now deconstruct, slightly, by this article.  In the late ’50’s and early ’60’s, I was a youngster with anxiety, tics and other nervous behaviors including a hideous blight of trichotillomania – hair-pulling.  I regularly chewed holes in my tee shirts, churned my neck, bit my lower lip bloody down to the nerve, sewed with thread patterns in my thumb, well callused by continual gnawing.  The bald was a massive, irregular continent shape.  No one said a single word to me, ever, nor was any therapy or other treatment ever provided.  My uncle, formerly an obstetrician and at the time a bona fide psychoanalyst who saw patients at his Park Heights Avenue condominium, never talked to me, and maybe not to my parents.  And they said nothing, but eventually took me to a hairpiece maker who fabricated a custom toupee.  A mediocre story writer couldn’t have come up with a more obviously condemning symbol for “cover up the problem.”

A psychotherapeutic throw-back or curmudgeon – take your pick – I pay indifferent homage to genetics’ likely implication in some psychological disorders, and generally consider the notion a cop-out that deserves to be laughed then kicked out of court.  Much more active than genetics are influences of powerful forces that are in the hands of parents or others.  Following is the abstract of an article, “Relationship of maternal and perinatal conditions to eventual adolescent suicide,” published in the March 16, 1985 edition of The Lancet:

“In an investigation of a possible relationship between falling perinatal mortality and rising rates of adolescent suicide, 46 risk factors from the prenatal, birth, and neonatal records of 52 adolescents who committed suicide before age 20 and 2 matched controls for each subject were analysed blind.  The results showed statistically significant differences between the suicide victims and each of the controls and no difference between the controls.  Three specific risk factors were shown to have a powerful capacity to differentiate the suicides from the controls: (i) respiratory distress for more than 1 h at birth; (ii) no antenatal care before 20 weeks of pregnancy; and (iii) chronic disease of the mother during pregnancy.”
Respiratory distress at birth along with an impaired mother, and mothering, leads to suicide thirteen to twenty years later.  Psychology is biology the younger we are, a fact that sublimates (I mean this more as the chemical definition of refine or purify, not the Freudian take) “blame” of parents to non-blame, but leaves “responsibility” undisturbed.  And the responsibility is: Don’t blame the goddamned genes.

I can tell you what happens when tics, and the person, are ignored.  At age 30, working as a typographer in Sarasota, Florida, I kept in my wallet a handwritten list of approximately twenty tics that I both cherished, perversely, as my identity neurosis and desperately determined to abolish.  Included were thumb-deforming squeezing and clicking; snapping upper and lower rows of teeth together; neck churning; brusque sniffing; finger stretching; foot churning; flicking back of teeth with tongue; sliding, in dreamy patterns, tongue over teeth; intensely compressing nostrils by muscular contraction; swallowing air; chewing skin off fingers and flicking it across the room.  Though the tip of the neurotic iceberg, these acts were essential to my identity, like skin, as they kept submerged the ghosts that, paradoxically, were the dreaded real self, the ungrown child.  In time, I mastered most of them by brute and depressingly vigilant force.  But right now, thirty-two years further on: The thumb is squeezed, and clicks.

Picture this truth: Tics are the compressed energy of impossible silence in the face of insane loss.  A father who does not talk to his son is the world gone wrong, essentially killed.  Say goodbye to that world, but without words, without sympathy.  Dull or divert your eyes from this grandest of all sights, because nobody cares.  And many years later, see the tic as the history of all the unsaid, un-had, ungiven.  How mute it is!  And because it should never have been mute but instead the language of meaning, color, life, it is awe-fully eloquent. 


Saturday, November 30, 2013

Casual Saturday #2


On birthday no. 62, I feel pressed to wonder why my sister thinks there is a connection between us that goes either way.  Always less troubled than I (this is my generous assumption), and with what always seemed a gentle-superior air but which I came to see as her unconscious fusion of concern (a purposely ambiguous term), lack of affection, and anxiety (and some solipsism, where it is terribly difficult for one beleaguered sibling to “empty out” and have empathy for the other), she has long fooled herself into thinking something exists.  While it may seem preposterous of me to suggest that someone does not feel affection who claims she does, I know very deeply that through all our formative years and well beyond, I was absolutely unlikable.  My own fusion of alienation, seamless neurosis and developmental abort even in the midst of the latency years, created a revolving gun-mounted turret of toxicity that would have shot away any touch, blink, laugh or word of affection, and created distaste in the other party.  And anyway, I would remember if there had been even a stroke of fondness from any of the other three in the house.

And so, I’ll say this is as good a time as any to state a terrible but obvious truth: There was never a family when families become, so there can never be one now.  Despite the fact that we may want it, it can’t happen.  Strangers may quickly like one another, eventually love.  Ruiners cannot.

Wednesday, November 27, 2013

Inner child deluxe


It may help those therapists who are dedicated to roots, causes and relative resolution of problems to give new respect to the idea of the inner child – that personification of our ungrown identity – but to see it in a different way. It is to conceive that persons with neurotic or psychotic dysfunction do not “have” an inner child – they are their inner child. This conceptualization goes even further than the Primal understanding that personality is a constellation of defenses, and asks you to consider that the adult life in its countless aspects is often the necessary fallback adopted to carry our crippled child into the future.

To see essentially a deluded child (who believes, that is, that he or she is actually grown up) in the chair doesn’t mean you must hold her or sing her lullabies or accept all his bad behaviors. Adultness is like free will: We must act as though it is genuine despite all the logical evidence against it (https://www.youtube.com/watch?v=pCofmZlC72g), and accept that it contains imperatives of social behavior. What's essential, though, is that you see the ultimate child beneath everything and therefore have compassion for irrationality and immaturity, and understanding that his confusion is not ignorant or willful. The depressed and repressed little girl cannot know.

You will see that the haughty narcissistic police officer is a bitter child whose father kicked him around. That the philosophical young phobe fell upward into his mind early on to escape unsustainable pain. That the psychotic woman has, as Modrow describe it, “undergone terrifying, heartbreaking, and damaging experiences, usually over a long period of time, and as a consequence [is] emotionally disturbed – often to the point of incapacitation.”* I have found in myself an extra quality of compassion, which I could call universal, that sees our adultness as a fix we are in, as translucent discolored lenses through which we try to see a bright and crystal clear world.

This perspective has helped me work with men who present with domestic violence or other rage reactions. They are boiling inside as there has never been any justice in their boyhood. Get slapped often and be ordered to be mature. We need to see – probably for the first time in the man’s life – that boy, to reach a hand out to him. I see him whenever I get angry -- deeply and disintegratively angry – at a computer screen that refuses to refresh as quickly as I require.

I, in fact, don’t understand how therapists work with the adult as the primary field. Beyond some weeks or months of support, education, reasoning and persuading –

“When years of interpretation have failed to generate change, we may begin to make direct appeals to the will: ‘Effort, too, is needed. You have to try, you know. There’s a time for thinking and analyzing but there’s also a time for action.’ And when direct exhortation fails, the therapist is reduced [. . .] to employing any known means by which one person can influence another. Thus, I may advise, argue, badger, cajole, goad, implore, or simply endure, hoping that the patient’s neurotic worldview will crumble away from sheer fatigue.” (Irvin Yalom, Love’s Executioner, pp. xvii & xviii.)
– what is there left that you do? But more: To look at the grown man or woman and see an entity simple – changeable by a new or “rational” idea; or shallow – bendable by the brute force of necessity, as in anger management; or appeasable by soothing – DBT “mindfulness,” EMDR “installation,” or imagery, is to limit yourself to such a foreshortened horizon! A newspaper instead of a history book! The inner child – the real self – is the field as deep as time, and capable of extending intimacy into the past, where we felt the endless horizon.

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* John Modrow, How To Become a Schizophrenic, pg. 9.

Sunday, November 24, 2013

Casual Saturday #1


A client, today, asked me how to become stronger than her parent, how to not melt to her powerful mother.  This is a bright twenty-something with a fifty-something whose power consists of having been sick long enough to infect the children by her solipsistic dark energy field.  She asks the question of maturity, or maybe the question of happiness.  Maturity means to be separate from the other.  A happy view of life means that she will not see her mother as a drowning dying person but as someone who, allowed to fall on her face once the daughter steps away, can feel good enough to get up, heal and walk on.

I sometimes talk of people having from birth a “positive core.”  Though not a scientific idea, it makes sense if you accept that most babies are born much more positive than negative.  That is, they are curious, seek happiness and love and help from pain.  Even most of those born in trauma who recoil from touch still had the blueprint of positive potential.  (My “theory” says that psychopaths are different – their heart burned out from the beginning.)  If my graduate student has this core of positivity underneath her weakened and diminished self, then if she grieves the pain of so much loss that surrounds it, the core’s quiet light will shine through.  Sometimes I ask a client to find her core while still troubled, as a lighthouse in her dark ocean.

As to maturity, we talked about natural self-esteem, logical self-esteem and fake self-esteem (the first two borrowed from “natural” and “logical consequences”).  Natural self-esteem is what grows in the young person organically in a loving respectful and basically content atmosphere.  You simply feel OK to be yourself.  I remember, early 1960’s, three young-teen second cousins sitting around the den with their asbestos litigation attorney father, Harry Jr., all farting up a storm and resplendently free of shame.  That was self-esteem!  Logical self-esteem would be to know and cherish that you are worth what other people are worth; to take pride in your surviving your childhood; to respect the quality of your competence – all this despite bad self-feeling or existential emptiness.  Fake self-esteem – which we may mix with the logical – would be narcissism.  I can’t, though, tell the young woman how to acquire this.

Two things we’ve settled on: It will be best for her to depart from home and start her life elsewhere; but, that it won’t be better for her: still the same person, still afraid of people in power, maybe afraid of everyone (we haven’t investigated that possibility).  Yet I picture her going away, growing, then coming home but being too big to fit into her parents’ house anymore.  “So sad when that happens!” Mrs. Doubtfire ironically said.

I’m sure there are many things better than psychotherapy to metamorphose one’s character in a sea change way.  I’ve wondered about the Outward Bound program that sends kids and others into nature, into beauty, to struggle and bond.  Hitting the end of the road may lead to character change, as it did for me.  Still, I put my money on deep grieving and the irreducible kernel of life force, the core of positivity that can kick fear’s ass, heal the sick and sing a love poem all together.  It is quite ambidextrous.



Friday, November 22, 2013

"Anxious Personality Disorder"


I’m thinking of nine former clients whose presenting problem was anxiety, whose fear – the original source of anxiety – had good solid reasons in birth or childhood, and who have remained fearfully developmentally immature in various ways.  A*, who could only make fleeting eye contact, had always been afraid of people.  By age thirty-one he’d stumbled his way through an uninspired college major and now followed the path of least resistance by getting cashier jobs.  He lived with an uncle who threatened on whim to cast him out.  B, seventeen years old and raised by an “old school” martinet father and an “always rushed” mother, works a roster of cleanliness obsessions and has the life sophistication of a fifth grader.  He’s never dated, assumes “everyone” finds homework “boring” and “flat-out” refuses to do it.  C, another obsessive-compulsive teen, has convinced himself that school is worth anything only to the extent it is “fun” and social; despite school has a near-reversed sleep cycle; and is faux-blithe and lite-fatalistic about his future.  D, mid-twenties and shaking like a leaf, lives with an unsympathetic relative, always feels he must give elaborate explanations of his behaviors, always feels he did something wrong, remains in thrall to his father who controls his money, and fears being abandoned by him if he were to get in trouble.  Like a surprising number of young lost souls, he is interested in pursuing a career in culinary arts.

E, pressed by her father never to bring attention to herself, has long been unable to stand up to any authority, is afraid to tap on the door of her uncommunicative husband, and by home-schooling her three daughters is cultivating hot-house flowers who don’t date, speak no unkind words and make no waves.  F, sexually abused by a neighbor child and ignored by his parents, now in middle age plays with nostalgic toys, fears people laughing at him, has a contemptuous son who shoplifts and steals from the family, and suffers floor-shaking psychomotor agitation.  G and H, young men, are in abject fear of their elderly fathers, have given up seeking employment owing to extreme psychosomatic reactions, live in the frail ivory tower of their thinking and worrying.  I, age sixty, suffers chronic anxiety, is scared to drive beyond her neighborhood, complains “I hate having to be strong for myself,” and nurses a reversal-of-parenting self-pitying rage about her adult son’s failure to love her.  “Why can’t he be loving?” she asks.  The notion that she, the parent, might be the magnanimous one is shot down.

By its Axis I status, anxiety is tacitly conceived as a “pure” problem – as if it struck an otherwise hale or lucid individual from the outside by traumatic event or environment or bad chemical – and not as if it were character.  But the clients described here show not only a disease incursion but a personality, as each one’s anxious dependency and immaturity are ego-syntonic, a term that means “in harmony with one’s self-view.”  Just as one would be hard pressed to find a Narcissist upset that he feels so good about himself, or a sociopath who wishes he had a conscience, so these frightened people do not hate their passive, or dependent, or non-mature natures.  Hatred might be power that laughs a cruel father into his corner, or a clean loud laugh that says I’m moving out and let the damned chips fall where they may.  Instead of hate, they timidly dislike, or even “love” and roll their eyes.

Fear has through the developmental stages kept them immature, and immaturity then keeps them fearful.  What do we make, then, of The Anxiety & Phobia Workbook and all the techniques that one applies, like lessons or lotion, to someone whose fear is an integral feature of their regressive development?  Are breathing exercises and “positive counterstatements” – “I am confident and calm about boarding the plane”; “I’m lovable and capable” – going to help a scared-to-death lonely child?

Later I’ll write about deep help for anxiety.  This will include the question: Can we “heal” immaturity, the loss of critical times and growth within us?


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* Names are eliminated and identifying facts are discombobulated, yet I can picture each person very clearly.

Tuesday, November 19, 2013

Silence


Therapists know from their training that silence can be a powerful factor in the session.  Somewhere it was written that heavy moments of silence can, under pressure, draw from the client profound chunks of self insight, as the first words brought from the dark to light.  It is true.  Often I value the silence itself, knowing that for many people quieting the ever-talking head can bring someone to a new, deeper universe.  Anything found in that forgotten place must be valuable.

Other silences, though, have other meanings, may be less helpful or not helpful.  I’ve sometimes indulged – that is, let the client indulge – in these silences.

A twenty-two-year-old man, naïve and even somewhat cardboard in character, sat in doe-eyed silence for forty minutes, and again in the following session.  What kind of resistance was this?  There is, of course, fear to know oneself, fear to show oneself, defiance, and what Levenkron* and others call the client’s “emptiness.”  During a parents-only session, I learned that he has lied to them about his academic goals in college, lied about a relationship, lied about expenses he'd incurred.  Already known, through earlier meetings, was that as a youngster he’d been complaisantly compliant to a “busybody” mother.  What was this silence?  I believe it was the emptiness of the undeveloped emotional soul plus his way of standing up to me: Like lying to his parents, age twenty-two going on twelve, he could lie to me by omission – complete omission.

More recently I allowed a seventeen-year-old boy to stonewall for most of the hour.  He not only performed complete silence with no eye contact, but made sure not to move a muscle, not a finger drumming or a neck straining, for fifty minutes.  (The final ten minutes, I talked to him about his silence, about the loneliness possible to one who remains silent before friends and help, and cited Yalom’s group therapy intervention: Imagine this was your final meeting, you’ve said goodbye to the other members and are heading out the door for the last time.  What would you regret that you never said?)

This client had already had several sessions that, helpful in the face of his floaty numbness, I had filled with compassionate education and a few questions.  He was quite troubled sexually, reactively and proactively, had been lifelong overpowered by a revenge-filled father, let down by a passive and fey mother.

What was silence doing with these boys?  I’m not sure I could even allow them to say it was painful or angering or a waste of time, or boring.  I think we all need silence.  It brings us closer to our real self.  We stop and sense what we’ve been walking past, eyes averted, our whole life.  We also quiet our psycho-agitated body.  Then, the tension that supplies all the tics, squirming, leg tremor, repositioning is now felt for what it is: the message of life’s frustrations, always importuning.  If this tension-frustration could be translated back to what it is, at once, we might hear the screams of a million losses; we’d feel the impossibility of it.  This would be a kind of psychosis: How did I survive this?

The question of allowing too-long silences (most are only a minute or two) raises again the matter of what healing means.  While something narcissistic and benevolent in the therapy room causes me to value, each time, all possible gradations of help – intent listening, a piece of music, ratifying the client’s suspicion that his wife should stop supporting her addicted son – I love the deep journey the best, the moments of truth and drastic feeling.  These must take place in a quiet room, even “quiet” of bright light.  Long quiet is the clocks being stopped, the running stopped, the treadmill through forty years stopped, everything stopped but who you are.  So let it be uncomfortable.


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* Steven Levenkron, Obsessive-Compulsive Disorders